Tracking and Explaining the Repealing and Replacing
An overview and analysis of how news orgs are covering U.S. health care
Earlier this year, when I started reporting an article about how repealing and replacing the Affordable Care Act (ACA) might affect people in Cook County, Illinois, I quickly realized I was in over my head. Breaking down the implications of the American Health Care Act (AHCA) felt important—I’d heard so many stories of people struggling to navigate the health care system lately, both in news coverage and in conversations with friends and family. But I had little experience covering health insurance and health care systems. These systems and the laws that govern them are complex, and they affect different groups of people in dramatically different ways. To make the task even more complicated, neither the actual contents of the legislation nor a score of the AHCA by the Congressional Budget Office (CBO) was available at first. When these finally became available, it was a sprint to parse them, understand their implications, and share these findings with the public as clearly as possible.
To understand the context of the legislation and backstop my own reporting, I read a mountain of coverage from a variety of news organizations. While I wasn’t able to report on the legislation as it moved from the House of Representatives to the Senate, whose version of legislation is the Better Care Reconciliation Act (BCRA), I have continued to follow news coverage.
This is a by-no-means exhaustive overview of health care legislation coverage that I found useful, interesting, or innovative. I’ve chosen to skip coverage of the political clash surrounding the legislation and focus on coverage that explained how health insurance and health care work now, what might change under the proposed legislation, how people with lives different from the reader might be affected, and how readers might engage with their elected officials on the issues intersecting with the legislation. If you’ve seen some great coverage of the AHCA and BCRA, particularly stories that use data or present concepts visually, please share them with me at email@example.com.
Understanding the CBO Analysis
On June 26, the CBO released its cost estimates of the Senate bill. Many reports on the CBO’s analysis included some version of a chart showing how the number of uninsured would increase dramatically under the BCRA.
And here’s Politico’s:
The Washington Post took a slightly different approach and showed the number of uninsured rather than the rate:
The New York Times also showed the number of uninsured people, but in a different way—showing the number under the BCRA alone in one chart…
…before adding the projection under current law:
The Times chart didn’t show the projection for the AHCA.
The CBO analysis itself includes some informative charts and tables, including one that breaks down changes in the number of uninsured by age group and income, one that shows the decreasing number of people insured by Medicaid, and this one that shows the effect of different aspects of the bill on the federal deficit:
Vox thought that this chart was so significant that it wrote a post about it, elaborating on the connection between the budget deficit, Medicaid coverage, and tax cuts.
The CBO report also included this chart showing projected Medicaid expenditures under the BCRA and current law.
The president tweeted a version of this chart that only showed the increase in spending projected under the BCRA. Vox published an explainer that included this GIF showing why omitting the projection for the current law is misleading.
With both the AHCA and BCRA, the actual costs of insurance bought on an exchange can vary a lot. To really understand the reasons for the final cost, we have to look at both changes to premiums and changes to tax credits, which were a fundamental part of the ACA. Making it even more complex, the changes in cost vary by age and income. While one could represent these changes as a table or as bar charts, the New York Times used arrows to visualize changes to insurance costs described in the CBO’s analysis.
I found that the arrows more clearly expressed who would see an increase or decrease in costs than a table or bars would have. I also liked how this visualization captured costs under existing health insurance policy.
Showing Who is Affected, and How
Different people pay for—or struggle to pay for—health care in different ways, and their health care needs vary dramatically, too. With this complexity in mind, I looked for reporting that quantified the bill’s effects on specific groups of people.
In “Who Wins, Who Loses With Senate Health Care Bill,” NPR broke out different groups of people and provided easy-to-understand statements about how current law, the AHCA, and the BCRA would affect those groups.
I like this treatment because it is easy to conflate the changes proposed by the AHCA and BCRA, and this grid makes the differences between the two pieces of legislation clear. This grid also makes it possible for a reader to quickly see the implications for their personal situation, without hiding any information about other groups. The design acknowledges, for example, that a person under 26 may be deeply curious about the bill’s effect on low-income nursing home residents if they have a grandparent who falls into that category.
I’d like to see a news organization go all in with this kind of visual treatment, linking out to news coverage in each cell of the grid, and finding a way to embed the grid in follow-up stories, to consistently give readers this level of context about how the bill affects certain groups.
The NPR grid, and the simple chart below from the Upshot’s “G.O.P. Health Plan Is Really a Rollback of Medicaid,” provide value beyond just the numbers and analysis. The categories of people identified in these charts become a useful taxonomy for readers that they can use to frame other coverage.
The FiveThirtyEight explainer “What The Senate GOP Plan Would Mean For Health Insurance” breaks down the effect of the legislation using a different set of groups: the way in which people are insured.
FiveThirtyEight also published a series of charts about the AHCA, including this one below. This chart highlights an important dynamic that underlies the policy debates. Most people receive health insurance through an employer, while the people most impacted by both the ACA and the repeal of some of its provisions are covered through Medicaid or the non-group market.
The proposed policy changes, and the people most affected by those changes, aren’t separate discussions. But it is challenging to visually represent how these factors intertwine. Vox’s “This chart shows the stunning trade-off at the heart of the GOP health plan” tries to contextualize tax cuts for wealthy people relative to the cost of insuring Medicaid recipients who stand to lose coverage, according to some analysis.
I found it difficult to parse this comparison between households, individual enrollees, and dollars, but I would like to see more attempts to contextualize the quantities involved in health insurance policy. Whether examining premiums, tax credits and penalties, lifetime caps on coverage, or numbers of insured and uninsured, scaling one set of numbers to another can help show financial trade-offs.
While not a news organization, the Kaiser Family Foundation’s (KFF) research and analysis is often cited by health reporters. The KFF’s frequent policy briefs often provide numeric context for the legislation. “Facilitating Access to Mental Health Services: A Look at Medicaid, Private Insurance, and the Uninsured” provided a series of charts that broke down insurance status, and the significant role of Medicaid for people accessing mental health services. The KFF’s charts are dense and seem directed at an audience which has been following health policy. I appreciate that their charts consistently have good source lines, which I use to help understand when different news organizations are offering different representations of or takes on the same data. I also use the source lines to identify data sets to review or track for my own reporting.
The AHCA/BCRA could mean big changes for people who access health care through Medicaid. The legislation sets an end for federal funding of the expansion of Medicaid coverage, ties federal Medicaid funding to population or a fixed amount rather than health care costs, and moves toward more state control of how they implement Medicaid. NPR in partnership with Kaiser Health News, an editorially independent news organization funded by the KFF, published “In Texas, People With Fluctuating Incomes Risk Being Cut Off From Medicaid.” This story looked at how Medicaid recipients with fluctuating incomes navigated health coverage in Texas, a state that verifies Medicaid eligibility based on income every month.
The reporter, Shefali Luthra, does something important when writing about policy topics that are heavily informed by data—identifying gaps in administrative data. Luthra writes:
Texas has not tracked how many children lose coverage because of income testing. But in September 2014, a month before this practice began, just under 10,000 children on Medicaid faced a gap in coverage of three months or less. By June 2016, the most recent month for which Texas could provide statistics, almost 23,000 children experienced such a gap.
Geography also plays a large role in how people experience health insurance costs. The Washington Post used maps to compare premiums under current law, the AHCA, and the BCRA across the nation in “See where the Senate health-care bill’s subsidy cuts will affect Americans most.”
Axios showed the interplay of age, income, and geography on premium prices with this grid of choropleths.
The KFF, whose analysis was the basis for the Post graphic, published an interactive that allows users to view projected premium changes under the BCRA for a specified income and age. It also lets the user see the changes on a per-county basis.
KFF previously published an analysis of how premiums could be affected for every county in the U.S. This was the source for visualizations such as “Health Care Plan Championed By Trump Hurts Counties That Voted For Him,” by NPR.
The Economist used the same data, but it presented the premium changes as a percentage of income and plotted the change in premiums relative to the percentage of votes that went to Trump in any given county.
Describing geographic differences in Medicaid coverage, KFF has also compiled fact sheets for each state that show the impact and extent of Medicaid coverage in that state. The menu for downloading fact sheets is a choropleth of the percentage of people in each state covered by Medicaid.
I like how the graphic lets the viewer spot geographic trends with the map, while the chart below lets them see how a given state compares with the rest of the nation.
Medicaid funds are particularly important to small, rural hospitals, according to this report, a partnership between NPR, KBIA, Side Effects Public Media, and Kaiser Health News. Additionally, some states have “trigger” laws that would end Medicaid expansion if federal funding drops below a certain level, as visualized by this Washington Post map.
Using squares, instead of the state boundaries, works well for this visualization because it still lets the viewer see geographic trends, like the cluster of Midwestern states with trigger laws, while making it easier to quickly count the number of states with or without the laws.
To give context to geographic differences, the New York Times aggregated coverage from publications across the U.S. in “Senate Health Bill Gets a Wary Reception, From Coast to Coast.” As Senators returned home for a recess, Politico writer Dan Diamond collected front-page coverage from local papers.
One of the challenges under the ACA has been insurers exiting exchanges leaving residents of some counties with a single insurer. Some counties even face having no insurers in 2018. The Associated Press made a map showing counties with only one provider:
As did the Upshot.
Vox shared this more recent version that I saw shared in a tweet:
NPR published a text-based explainer that broke down the ways that the AHCA could change health care for women, while Vox published an AHCA explainer focused on birth control. Quartz’s analysis of a KFF issue brief highlighted that Medicaid cuts would disproportionately impact many states with a sizeable black population.
While I’ve focused on exploratory, data, and visual pieces in my review of coverage, I found another kind of coverage really valuable: the stories of individuals representing groups of people with specific health care needs that are often difficult to quantify. The Outlook published portraits of seven transgender people in “Health Care is a Human Right,” along with statements about how each person accessed health care and their concerns with a potential policy shift. I also appreciated coverage of how health policy intersects with the lives of professional skateboarders, nursing home residents and people with disabilities who receive “optional services” under Medicaid.
Explaining How Insurance Works
The ACA was complicated. The AHCA/BCRA are complicated. The health insurance policy you get from your employer, on the individual marketplace, or through Medicaid is complicated. Unsurprisingly, the economics that underlie health insurance are also complicated.
Vox published “How the Senate’s revised bill punishes you for not having insurance, explained with a cartoon” that tries to explain the challenge facing insurers to retain a mixture of healthy and sick people in their insurance pools. It used the BCRA’s six-month waiting period for people to re-enroll if their coverage lapses as an opportunity to explain a more fundamental concept and compare the Senate proposal to existing law.
Other highly specific explainers, such as Marketplace’s origin story of employer-sponsored insurance in the U.S., helped me cut through the complexity of health policy and explain some of the dynamics behind charts.
Tracking the Legislative Process
After last November’s presidential election, the New York Times published “Can Republicans Repeal Obamacare Piece by Piece", a scrolling interactive that broke provisions of current health care law into digestible chunks and explained the path to repealing each provision.
The Washington Post’s “What’s next for the Republican health-care bill” does a great job of tracking the path of the legislation in a clear, visual way. It centers on the most recent actions while making it easy to navigate back in time, or look to the future, in the life cycle of the bill. This tracker is also a good way to organize and link to the Post’s ongoing coverage of the legislation.
The bill is moving through the Senate via a budget reconciliation process, which makes it more difficult for senators who oppose the legislation to block the bill. However, reconciliation is limited by the Byrd Rule, which governs the type of provisions that can be in the legislation. Vox published an explainer on reconciliation and the Byrd Rule, “The obscure Senate rule that still could save Obamacare, explained,” which helped break down the procedural complexity.
Understanding What’s in the Bill
While the text of the AHCA (and the BCRA) is publicly available, the language and format of the legislation can be challenging for those not used to reading legislation. A simple bulleted list of elements of the bill, such as the one in the New York Times’ “What’s in the AHCA: The Major Provisions of the Republican Health Bill” is a good reference when following other coverage.
Axios also published a text explainer of changes in the AHCA and BCRA. Their explainer included a summary at the top and used emoji to convey the risk to different aspects of the system. This is a simple and easy way to facilitate visual scanning of a text-heavy story.
The Washington Post used a visual approach to show changes between current law, the AHCA, and the BCRA in “What the Senate bill changes about Obamacare.”
KFF also published a tracker, “Compare Proposals to Replace The Affordable Care Act,” that offers a comparison of even more policy proposals such as draft versions of the AHCA and other plans by congressional Republicans that preceded the AHCA.
The New York Times used a “repeal, change, and keep” framework for its visual representation of the Senate bill. It opens with a graphic that introduces us to the colors and categories we’re about to encounter throughout the piece—serving the same purpose as a visual lede, orienting us.
Documenting What Representatives are Saying
While the public waited to see the contents of the Senate version of the bill, Vox reporters asked a few senators a series of simple but important questions in “We asked 8 Senate Republicans to explain what their health bill is trying to do.” These questions, such as, “Generally, what are the big problems this bill is trying to solve?” and, “How do you think the bill will fix that problem?” not only help the audience gauge how well senators understand the legislation, but also give the audience framings for evaluating the policy as they consume other coverage. The article was published as a transcription of the questions and answers. This proved to be a simple, but effective story form that Vox also used to try to get at Democratic senators’ policy visions for improving health care policy. Focusing on big questions is a strategy that could also frame visual or interactive journalism.
In addition to traditional reporting and analysis, I’ve found it useful to read statements directly from elected officials on the health care bills. ProPublica’s Represent is a good example of a general-purpose news application that can focus on particular stories or topics. Users can search for press releases from congressional representatives and access topic pages such as the one for “Affordable Care Act Repeal.”
If you’re developing your own application, these statements are also available through ProPublica’s Congress API.
curl https://api.propublica.org/congress/v1/statements/subject/affordable-care-act-repeal.json -H "X-API-Key: $PROPUBLICA_API_KEY"
ProPublica, in partnership with Kaiser Health News, Stat, and Vox fact-checked statements by lawmakers on the ACA and AHCA. ProPublica also invited audience members to share responses from their representatives with the news organization as part of their fact-checking.
Most representatives also have email newsletters which are a rich source of information about where representatives stand on legislation, how they frame the issues that intersect with legislation, and the sources that inform their decision making. I’ve been tracking some of these newsletters for a reporting project, and I would love to see an effort to collect these and share them in bulk.
The New York Times tracker also includes snippets from statements about the lawmakers’ positions on the bill.
Leading up to a March vote that was ultimately cancelled, NPR and WNYC collaborated to create an interactive tracker where users could filter results to a particular state’s lawmakers, and view lengthy statements from senators and representatives.
In May, the New York Times published a visualization of how members of the House of Representatives voted on the AHCA as well as an analysis of Republicans who initially opposed the legislation and then flipped their vote, as well as those who ultimately voted no.
The Washington Post also published the House’s votes on the AHCA including these charts showing how it was conservative Republicans who flipped their support.
The results of roll-call votes such as the one on the AHCA are available through ProPublica’s Congress API.
curl https://api.propublica.org/congress/v1/115/house/sessions/1/votes/256.json -H "X-API-Key: $PROPUBLICA_API_KEY"
Using New Channels, New Reporting Methods
I’ve mentioned work by Vox a few times in my overview of coverage because they seem to have really committed to covering the push to change health policy. As part of that coverage, they created a newsletter, VoxCare, which provides daily updates on health stories. You can find NiemanLab’s writeup of the newsletter here.
In 2016, Vox also created a Facebook group that served as a hub for many different types of engagement around Vox’s health care coverage. In the second-quarter 2017 issue of the IRE Journal, Vox senior engagement editor Lauren Katz writes about lessons learned, and explains how the group has helped find sources, shape coverage, and compel officials to be interviewed.
What I Didn’t See
Specific landing pages for coverage.
The story of GOP attempts to roll back health policy breaks the way most news organizations categorize their coverage. It’s a national story, but there are distinct local concerns. It’s definitely a story about politics, but understanding the details of how people access health care is just as important as how representatives will vote on legislation. The movements of insurance companies, which might generally be covered in the business section, have significant political and personal relevance. For this reason, I found that the section pages of many news websites weren’t very helpful for discovering stories about the AHCA and BCRA. I found most of the pieces I’ve mentioned through social and search and would have been interested to see more news organizations make specific landing pages for coverage of the bills.
Explainers connected to breaking news.
Vox used its storystream form to collect stories related to the GOP legislative effort, but even this story-specific aggregation arranged the individual pieces chronologically. While a temporal organization of stories might make it easy to track the movement of the legislation through the House and Senate, or highlight representative’s changing positions, I found it was not the best form for discovering explainers, coverage about specific provisions of the legislation, or the legislation’s potential affect on particular groups of people. The Washington Post’s explainer, which I mentioned earlier, linked out to some of the Post’s other coverage, and I would have loved to see this expanded further, using the chunking of concepts provided by the explainer to organize all of the Post’s topical work. Similarly, I didn’t see news organizations consistently linking between stories about the political wrangling of the bill and explainers about the BCRA and the AHCA.
Reporting that surfaced other stakeholders.
The week after the Senate legislation was released, the National Association of Medicaid Directors board of directors and the American Medical Association issued statements opposing the BCRA. Most of the coverage I saw focused on politicians and people accessing insurance and health care, which is understandable. However, as the statements indicate, there are many other types of people implicated in the United States’ health care system such as state governors or those who run free health clinics. I would have liked to see visual journalism, similar to the congressional trackers, that surfaces these other groups and orients them around the policy issues embedded in the health care legislation.
Local visual, interactive or data-focused reporting.
Given the significant differences in how communities would feel the effects of the bills, I wasn’t able to track much local coverage, such as this round-up of expert perspectives on the Senate bill from Crain’s Chicago Business or the Tyler Loop’s explainer post on how the BCRA could affect Tyler, TX. If you saw great examples of local coverage of the AHCA and BCRA, particularly ones that used data or explained concepts visually, please share them with me at firstname.lastname@example.org.
Geoff is a Chicago-based freelance news applications developer and reporter. His reporting interests include criminal justice and immigration.